Patient Care Coordination Variance Reporting
|
|
- Ann Shepherd
- 6 years ago
- Views:
Transcription
1 Section 4.8 Implement Patient Care Coordination Variance Reporting This tool provides an overview of patient care coordination (CC) variances, suggestions for documenting and reporting on variances, and policies and procedures for variance reporting. Time needed: 15 hours to review tool; set up documentation form, tracking mechanism, and reporting structure; establish policy and procedures for use; and introduce CC variance Suggested other tools: Patient Care Coordination Variance Reporting Log Template; Patient Care Coordination Variance Reports Template; Workflow and Process Analysis/ Redesign/ Optimization for CCC tool suite Table of Contents How to Use... 1 Overview of Patient Care CoordinationVariance Reporting... 2 Types of Patient Care Coordination Variances... 2 Variance Log / Checklist... 3 Documentation, Tracking, Analysis, and Reporting on Variances... 5 Workflow for Documenting, Tracking, Analysis, and Reporting on Variances... 6 Variance Reports... 7 Individual Variance Report... 8 Policy and Procedures for Patient Care Coordination Variance Reporting... 8 Introducing Patient Care Coordination Variance Reporting... 9 How to Use 1. Distinguish between a patient care coordination variance report, an (administrative) issues management program, and a risk management program. 2. Review the types of patient care coordination variances that may occur or be identified through a community-based care coordination (CCC) program. 3. Review the suggestions for documenting, tracking, analysis, and reporting on variances. Make modifications to suit the needs of the CCC program. 4. Draft policy and procedures for using the Patient Care Coordination Variance Reporting tool. 5. Introduce the policy and procedures for Patient Care Coordination Variance Reporting to the CCC steering committee, physician champion and others as applicable to obtain feedback and make adjustments. Distribute the tool and policy/procedures for use to those who may be documenting variances, aiding in addressing variances, and receiving variance reports. Section 4.8 Implement Patient Care Coordination Variance Reporting - 1
2 Overview of Patient Care Coordination Variance Reporting A patient care coordination (CC) variance is a deviation from a standard of practice or a specific care plan. Tracking patient care coordination variances can help a care coordinator (CC) identify patterns that may lead to improvements. A variance might be considered similar to a health care incident, or even a sentinel event depending on its severity. Variance is the more commonly used term when associated with care coordination, case management, utilization review or other processes that are proximate to but not direct patient care. A patient CC variance may be related to an action or outcome. A variance in an action can include: Something performed that was not intended to be performed (e.g., patient was required to have a repeat diagnostic test because the results of the first were not provided to the intended recipient) Something performed at the wrong time (e.g., a patient transportation company came a day earlier than requested) Something that was not performed that should have been performed (e.g., Mealson-Wheels did not supply food for an entire day) A variance in an outcome is a result of an action that is different than expected. An outcome may or may not be directly related to a variance in action. An outcome can be positive or negative, although usually it is the negative, or adverse, outcome that rises to the level of a trackable outcome variance. Administrative issues that might be logged, investigated, resolved, and reported upon for quality improvement are similar to patient care variances, but are associated with program administration and are not specific to a patient s care coordination needs or direct patient care. For example, a CC may consistently not have time to document care coordination activities, or may have lost a mobile computer device. Most health care organizations have an issues management program in which to make such reports and have them addressed. A variance reporting system for the CCC program may be patterned after an issues management system. Risk management also has characteristics that are similar to variance reporting and issues management but are focused on reducing the likelihood of economic, reputational, or litigious harm, often as a result of patient care incidents and sentinel events. Variances in care coordination or administrative issues associated with the CCC program may occasionally rise to such a level that they should be reported to a risk manager. Any time a variance could result in material harm to an organization it is appropriate for the CC to consult with the risk manager. A risk manager may also work with the CC as the CCC program is initiated to ensure that appropriate controls are in place and variance reporting and issues logging take place as applicable. Types of Patient Care Coordination Variances Patient care coordination variances may include five general types 1 and within each general type there may be a variety of specific types. Review the checklist below; it provides a number of examples in each specific type. Add, modify, combine, or delete specific types of variances as applicable to the nature of the CCC program. Within each general type there are both action and outcome variances. Section 4.8 Implement Patient Care Coordination Variance Reporting - 2
3 Although the specific types of variations are listed in the general sequence as they may be encountered from the start of recruiting a patient into a CCC program, many of the types that apply in the early stages of the program may apply throughout a patient s participation in the CCC program. For example, the fact that a patient is a poor historian may be recognized during the recruitment visit and this is repeatedly confirmed throughout provision of CCC services. Consideration might be given as to whether poor historian should be further qualified in an attempt to determine root cause, or whether it is documented the first time it is observed and not thereafter except in an unusual circumstance. There is value to maintaining consistency in documenting variances as frequency of occurrence can highlight the need for further investigation and quality improvement initiatives. Decisions about how variance logging should be performed should be described in policy and procedures so consistency can be maintained. Once satisfied with the types of variances on the checklist, the checklist becomes a Variance Log. Use it to log actual variances. Over time, refine the variation types where it may be appropriate to combine, split, delete, or add to the types. This checklist is set up to log variances on a quarterly basis by simply recording a hash mark for each variance. A database may also be established to log a patient identifier instead of a hash mark for ease of reference. (See Patient Care Coordination Variance Reporting Log Template for a fillable form.) Variance Log / Checklist VARIANCE LOG Variance # and Type of Patient Care Coordination Variances Q1 Q2 Q3 Q4 A. Patient-related 1. Declines data sharing 2. Does not keep appointments 3. Is a poor historian 4. Is not comprehending the CCC program 5. Language barrier 6. Withholds pertinent information 7. Forgetful (e.g., forgets glasses, keys, wallet) 8. Refuses provider appointments 9. Health literacy poor 10. Computer literacy poor 11. Unable to take medications as instructed 12. Refuses to take medications as instructed 13. Refuses community services (e.g., transportation, support groups, medication reminder aids, ADL help) 14. Refuses to maintain a health diary or PHR 15. Abusive, threatening or other behavioral issues 16. Medical complication occurs (e.g., pressure ulcers, wound infection) 17. Adverse reaction to medication 18. Medical event occurs (e.g., condition worsens, new condition occurs) 19. Other (specify): B. Family/caregiver-related 1. Language barrier 2. Health literacy poor 3. Computer literacy poor 4. Unable to provide care 5. Refuses communications 6. Desires second opinion Section 4.8 Implement Patient Care Coordination Variance Reporting - 3
4 VARIANCE LOG Variance # and Type of Patient Care Coordination Variances Q1 Q2 Q3 Q4 7. Not accessible 8. Cannot afford medication or necessary medical equipment 9. Abusive, threatening or other behavioral issues 10. Other (specify): C. Institution- or CCC program related 1. Capacity issues; lack of timely appointments; no open access 2. Data sharing issues; lack of technology, HIPAA concerns 3. Long wait times 4. Lost records, requisitions for tests or reports 5. Appointment cancellations; frequent re-bookings 6. Experience of care unsatisfactory to patient 7. Poor contact with care coordinator 8. Lack of specialty provider in community 9. Prolonged turnaround time for referrals/consults 10. Prolonged turnaround time for diagnostic tests 11. Shortage of supplies 12. No hospice services available 13. No home health services available 14. No nursing home beds available 15. Pharmacist not available 24x7 16. Therapists not available on weekends 17. Other (specify): E. Practitioner-related 1. Delay in communicating care plan 2. Miscommunication with care coordinator 3. Miscommunication with interdisciplinary team 8. Practitioner not communicating with patient 9. Practitioner not communicating with family 10. Medication error 11. Non-compliance with formulary 12. Refusal to use patient agenda, health diary, or PHR 13. Patient teaching not done/incomplete 14. Delay in scheduling diagnostic tests 15. Wrong diagnostic tests ordered 16. Lack of follow up with patient or family 17. Delay in processing forms 18. Delay in arranging for referrals 19. Failure to inform patient or family/caregiver of critical health-related information 20. Failure to inform patient or family/caregiver of financial obligations 21. Other (specify): E. Community resources-related 1. No <insert type > service available 2. Frequent lack of capacity for <insert type > service 3. Services are late 4. Experience with service unsatisfactory to patient Section 4.8 Implement Patient Care Coordination Variance Reporting - 4
5 VARIANCE LOG Variance # and Type of Patient Care Coordination Variances Q1 Q2 Q3 Q4 5. Services are not affordable/no financial assistance available 6. Incorrect service is provided 7. Abusive, threatening or other behavioral issues from staff 8. Other (specify): Documentation, Tracking, Analysis, and Reporting on Variances The following workflow (see diagram on next page) depicts the steps and decision-making involved in documenting, tracking, analyzing, and reporting on patient care coordination variances: 1. Record the variance on the Variance Log immediately when a variance occurs. 2. Determine if variance is significant. o It is not significant if there is an adequate workaround such as heightened monitoring and/or follow up, it is unlikely to recur, or its recurrence will not cause harm or materially impact the CCC program. If the variance is patient- or family/caregiver-related, use professional judgment whether or not to document the occurrence in the patient s health record. o It is significant if there have been repeated occurrences for this patient/familycaregiver, institution, practitioner, or community service for which workarounds are not acceptable. 3. Determine if a significant variance also presents a potential material harm (economic, reputational, or litigious) to the patient, institution, practitioner or CCC program. o If so, or if uncertain, engage the risk manager. o If not, proceed to take corrective action. A corrective action plan should be developed, implemented (and documented in the patient s health record), and tracked until the variance has been corrected (with the outcome documented in the patient s health record). o Variances that are significant (both those which do and do not pose material harm) should be documented on a Variance Report (see below) in addition to the patient s health record and Variance Log. 4. Periodically analyze the Variance Log and Variance Report(s) monthly or quarterly depending on the number, types, and nature of variances. o If a significant variance occurs only one time and is able to be readily corrected, it may not need an action plan for improvement. o For significant variances that recur, or non-significant variances that recur to the point of potentially hindering the CCC program (e.g., takes too much time, draws too many resources, begins to impact patient experience of care), engage the CCC Steering Committee and/or Quality Improvement (QI) Committee in developing and implementing an action plan for improvement. Section 4.8 Implement Patient Care Coordination Variance Reporting - 5
6 o Because the community is involved in the CCC program, steps for improvement are very likely to draw from several members of the community. The action plan for improvement can also benefit from an analysis of the corrective action plans developed for each significant variance addressed throughout the period. This analysis may reveal patterns that can help avoid or more quickly mitigate a situation. o Revise the CCC program in accordance with the action plan for improvement, implement the improvement, maintain it, and report back to the CCC Steering Committee and/or QI Committee on the status of the improvement, celebrating success and taking corrective action as needed for further improvement. Workflow for Documenting, Tracking, Analysis, and Reporting Variances Section 4.8 Implement Patient Care Coordination Variance Reporting - 6
7 Variance Reports There are several ways to create variance reports. Some CCC programs use a combination of reporting tools and others prefer to use just one. The following are some suggested approaches: Aggregated report on all variances for all patients. If there is a relatively small number of patients in the CCC program or few variances for each patient, this is essentially an expansion of the Variance Log. It helps track programmatic variances. Document the type of variance by recording the variance reference number from the Variance Log. Provide a brief description of the variance, the patient s identification, whether or not it is a significant variance, who reported it, when it was reported, the date of the actual event (this may be different than the actual occurrence and if there is often a delay in reporting by a certain person or institution this could be a variance worth addressing for quality improvement), what intervention is planned (and updated with actual intervention if different than planned), date to follow up (and date actually followed up if different), whether escalation is necessary (add to whom and when escalation was performed), and the date resolved and outcome as applicable. An example is provided below. Note that where there may be multiple follow-ups necessary, additional rows can be used. Var # A12 Description Pt ID Signif? Report by Will not take X as claims drowsiness Report Event Intervention Yes CC 2/4 2/4 Ask PCP for alternative medication Call Pt to check on response to F/U Escalate? Resolved / Outcome 2/6 No 2/7 new Rx 2/11 No No more drowsiness Aggregated report on all variances for each patient. If a patient will be followed in the CCC program for a relatively lengthy period of time with the potential for many variances, the type of report described below helps track patient-specific needs. Patient Name: Pt ID: Start CCC: D/C: Var # Description Signif? Report by Report Event Intervention to F/U Escalate? Resolved / Outcome Individual report on each variance for each patient (see example below). This is a comprehensive description of a variance that occurred with respect to a specific patient with detailed information about the nature of the variance, how it occurred, what actions were taken, and a description of the outcome. While the content includes the same information as on the report forms above, the individual form allows for much more description and can be processed by various individuals. (Note: It is important to protect the confidentiality of this form. If it resides on a computer, the file should be encrypted. If it resides in a paper file, the file cabinet should be locked and located in a secure area. Copies made for discussion purposes should be numbered, accounted for after use, and shredded.) If such a form were to be completed for every variance for every patient, it would likely to become a burdensome process. In addition, using an individual patient report is not conducive Section 4.8 Implement Patient Care Coordination Variance Reporting - 7
8 to analysis across the CCC program. However, much like an incident report or sentinel event report, it is advisable to create such a report for any very significant variance, especially where multiple team members and resources must be involved in corrective action and/or where there is potential material harm (and escalated to a risk manager). Individual Variance Report Patient Name Pt ID Start CCC Discharged Primary Care Provider Contact Notified Variance Type # Description of Variance reported: Reported by: of event: Comprehensive description of variance event: Persons (and dates) notified of variance event Patient: Family/caregiver: Primary care provider: Risk manager: Other: Corrective action plan Interventions planned and dates: Interventions implemented and dates: Follow up performed and dates: Escalation performed To whom: : Follow up performed and dates: Resolution and outcome How resolved: deemed resolved: Person(s) involved in resolution: Person reporting resolution: Other: Follow up quality improvement planned How: When to be initiated: Who to initiate: Action plan: of implementation: (See Patient Care Coordination Variance Reports Template for fillable forms.) Section 4.8 Implement Patient Care Coordination Variance Reporting - 8
9 Policy and Procedures for Patient Care Coordination Variance Reporting Policies are statements that establish goals for the organization with respect to various important organizational elements. They provide guidance in making decisions about actions and create mechanisms for detecting, resolving, and preventing policy violations. A policy may be simple: All patient care coordination variances should be documented in a manner that supports individual follow up to resolution and analysis for quality improvement. Outcomes of analyses of variance reports should be reported to the Community-based Care Coordination (CCC) Steering Committee and Quality Improvement Committee as applicable. Procedures describe how to carry out policies. They provide the workflow descriptions, forms and formats for processing the operations associated with their respective policies. This Tool is essentially a procedure that can be modified based on the specific CCC program decisions. All policies and procedures should carry a date of creation, revision dates, title of person responsible for maintenance of the policy and procedures, and executive sign off as the policy is approved. Introducing Patient Care Coordination Variance Reporting The policy and procedures for patient care coordination variance reporting will likely go through a process of review and refinement, initially by the care coordinator, with the CCC physician champion, and then with the CCC Steering Committee and potentially the QI Committee. Once it is finalized, however, the organization supporting the CCC program should formally introduce it to all stakeholders. These would include all provider institutions, individual practitioners, and community resource organizations. It is advisable to use the CCC Steering Committee to help in the introduction to their respective stakeholders. Copies should be available to all stakeholders and the CC should be available to respond to questions, take comments, and document recommendations for future revisions. References 1 The five general types of patient care coordination variances are similar to those adopted by case managers, as described in the Case Manager s Survival Guide: Winning Strategies for Clinical Practice, Second Edition (2003), written by T.G. Cesta and H. A. Tahan, and published by Mosby, Inc. Copyright 2014 Stratis Health and KHA REACH. Updated 12/19/2014 Section 4.8 Implement Patient Care Coordination Variance Reporting - 9
Table of Contents for CCC Toolkit
Section 0.2 Overview Table of Contents for CCC Toolkit This document lists and briefly describes all the tools in the CCC Toolkit in alphabetic order. Time needed: As needed Suggested other tools: How
More informationCommunity-Based Care Coordination Maturity Assessment
Section 1.3 Assess Community-Based Care Coordination Maturity Assessment This tool identifies four levels of community-based care coordination (CCC) program maturity. The maturity level of a nascent or
More informationALLIED PHYSICIAN IPA ADVANTAGE HEALTH NETWORK IPA ARROYO VISTA MEDICAL IPA GREATER ORANGE MEDICAL GROUP IPA GREATER SAN GABRIEL VALLEY PHYSICIANS IPA
ALLIED PHYSICIAN IPA ADVANTAGE HEALTH NETWORK IPA ARROYO VISTA MEDICAL IPA GREATER ORANGE MEDICAL GROUP IPA GREATER SAN GABRIEL VALLEY PHYSICIANS IPA QUALITY IMPROVEMENT PROGRAM 2010 Overview The Quality
More informationAccountable Care Atlas
Accountable Care Atlas MEDICAL PRODUCT MANUFACTURERS SERVICE CONTRACRS Accountable Care Atlas Overview Map Competency List by Phase Detailed Map Example Checklist What is the Accountable Care Atlas? The
More informationNational Health Regulatory Authority Kingdom of Bahrain
National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD
More informationOccupation Description: Responsible for providing nursing care to residents.
NOC: 3152 (2011 NOC is 3012) Occupation: Registered Nurse Occupation Description: Responsible for providing nursing care to residents. Key essential skills are: Document Use, Oral Communication, Problem
More informationCommunity-based Care Coordination (CCC) Maturity Assessment RidgePointe Healthcare District
Who/What Program Elements Level 1. Beginning Level 2. Progressing Level 3. Intermediate Level 4. Advanced Organization(s) sponsoring CCC Providers Community services Patients (pts) Payers A. LEADERSHIP
More informationQuality Improvement and Patient Safety (QPS) Ratchada Prakongsai Senior Manager
Quality Improvement and Patient Safety (QPS) Ratchada Prakongsai Senior Manager Overview 2 Comprehensive approach to quality improvement and patient safety that impacts all aspects of the facility s operation.
More informationCLINICAL PRACTICE EVALUATION II: CLINICAL SYSTEMS REVIEW
Diplomate: CLINICAL PRACTICE EVALUATION II: CLINICAL SYSTEMS REVIEW A. INFORMATION MANAGEMENT 1. Does your practice currently use an electronic medical record system? Yes No 2. If Yes, how long has the
More informationImplementation Guide Version 4.0 Tools
Implementation Guide Version 4.0 Tools Program Overview Purpose of the Guide This Guide is intended primarily for INTERACT champions and trained educators who are responsible for implementing and sustaining
More informationRoot Cause Analysis (Part I) event/rca_assisttool.doc
(Part I) http://www.jcaho.org/accredited+organizations/sentinel+ event/rca_assisttool.doc Edited by Dr. E. Terry DIO Dr. S.K. Oliver OME Examines the reasons an error occurred Suggests changes to the system
More informationADMINISTRATIVE POLICY & PROCEDURE PATIENT SAFETY PLAN
PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure
More informationEHR Systems: Risk Management Strategies. July 2013
EHR Systems: Risk Management Strategies Today s host Theresa N. Essick, RN, CPHRM VP, Clinical Risk Management Ms. Essick has 35 years of experience in the healthcare industry and has a broad understanding
More informationImproving Clinical Flow ECHO Collaborative Change Package
Primary Drivers (driver diagram) Change Concepts Change Ideas Examples, Tips, and Resources Engaged Leadership Develop culture for transformation Use walk-arounds and attendance at team meetings to talk
More informationOPERATIONS MANUAL CARE CONNECTIONS PROGRAM LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES
OPERATIONS MANUAL CARE CONNECTIONS PROGRAM LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES SECTION: PATIENT REFERRAL and INTAKE PROCEDURES 1 P age 1 CCP Referral Procedure Referrals for the Care Connections
More informationCPC+ CHANGE PACKAGE January 2017
CPC+ CHANGE PACKAGE January 2017 Table of Contents CPC+ DRIVER DIAGRAM... 3 CPC+ CHANGE PACKAGE... 4 DRIVER 1: Five Comprehensive Primary Care Functions... 4 FUNCTION 1: Access and Continuity... 4 FUNCTION
More informationUNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN 2014 1 PATIENT SAFETY PLAN 2014 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Medical Center (UMMC) is to
More informationProposed Standards Revisions Related to Pain Assessment and Management
Leadership (LD) Chapter LD.0001 Proposed Standards Revisions Related to Pain Assessment and Management 1 2 Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement"
More informationA Case Review Process for NHS Trusts and Foundation Trusts
A Case Review Process for NHS Trusts and Foundation Trusts 1 1. Introduction The Francis Freedom to Speak Up review summarised the need for an independent case review system as a mechanism for external
More information3/30/2015. Objectives. Cooking Up a QAPI: Recipe for Success Under the new COPs Part 1
Cooking Up a QAPI: Recipe for Success Under the new COPs Part 1 Catherine Gill, MS, PT, MHA Director, North Kansas City Hospital Home Health Teresa Northcutt, BSN, RN, COS-C, HCS-D Consultant Objectives
More information2017 Good Catch Program: Blueprint Companion Guide
2017 Good Catch Program: Blueprint Companion Guide EXECUTIVE SUMMARY The following document provides guidance to accompany the recommended strategies listed within the Blueprint for Success, a comprehensive
More informationSunnybrook Policy: Disclosure of Adverse Medical Events and Unanticipated Outcomes of Care
Sunnybrook Policy: Disclosure of Adverse Medical Events and Unanticipated Outcomes of Care POLICY STATEMENT: It is Sunnybrook & Women's Policy, in keeping with our Mission, Vision, Values and philosophy
More information3. Does the institution have a dedicated hospital-wide committee geared towards the improvement of laboratory test stewardship? a. Yes b.
Laboratory Stewardship Checklist: Governance Leadership Commitment It is extremely important that the Laboratory Stewardship Committee is sanctioned by the hospital leadership. This may be recognized by
More informationGOALS. I. Monitoring the quality of health care for safety, effectiveness and efficiency and seek opportunities for improvement
MUTUAL OF OMAHA INSURANCE COMPANY UNITED OF OMAHA LIFE INSURANCE COMPANY PPO & MANAGED INDEMNITY MEDICAL & DENTAL PLANS EXCLUSIVE HEALTHCARE, INC. 2005 QUALITY IMPROVEMENT PROGRAM The Quality Improvement
More informationOutcome-Based Pathways Unilateral Total Hip Replacement And Unilateral Total Knee Replacement
Outcome-Based Pathways Unilateral Total Hip Replacement And Unilateral Total Knee Replacement Overview, Guidelines and Glossary of Terms Table of Contents Overview... 3 Outcome-Based Pathway Structure...
More informationPROMPTLY REPORTABLE EVENTS
PROMPTLY REPORTABLE EVENTS PURPOSE AND SCOPE To define the structure and responsibility for reporting unanticipated problems that occurs during the conduct of research. APPLICABLE REGULATIONS Policy II.02
More informationSchedule 3. Services Schedule. Occupational Therapy
Occupational Therapy Services Schedule 2014 Consolidated Services Version Template Final Version September, 2014 Schedule 3 Services Schedule Occupational Therapy Occupational Therapy Services Schedule
More informationMEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS
MEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS Implementation Toolkit Last Updated: 02/2018 OneCity Health Services 199 Water Street, 31st Floor, New
More information20 STEPS FROM STUDY IDEA INCEPTION TO PUBLISHING RESEARCH/ Evidence-Based Practice
20 STEPS FROM STUDY IDEA INCEPTION TO PUBLISHING RESEARCH/ Evidence-Based Practice Nursing Research/ Evidence-Based Practice Checklist (Version 31 January 2012) Specify the date in the left column when
More informationDepartment of Defense INSTRUCTION. SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP)
Department of Defense INSTRUCTION NUMBER 6025.17 August 16, 2001 SUBJECT: Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP) ASD(HA) References: (a) Sections 742 and 754 of the Floyd D.
More informationSchedule 3. Services Schedule. Social Work
Schedule 3 Services Schedule Social Work Page 1 of 43 TABLE OF CONTENTS SECTION 1 INTERPRETATION... 4 1.1 Definitions... 4 1.2 Supplementing the General Conditions... 7 SECTION 2 CCAC PLANNING AND REQUESTING
More informationSafe Transitions Best Practice Measures for
Safe Transitions Best Practice Measures for Nursing Homes Setting-specific process measures focused on cross-setting communication and patient activation, supporting safe patient care across the continuum
More informationUPMC POLICY AND PROCEDURE MANUAL
UPMC POLICY AND PROCEDURE MANUAL POLICY: INDEX TITLE: HS-PT1200 Patient Safety SUBJECT: Reportable Patient Events DATE: September 9, 2013 I. POLICY It is the policy of UPMC to encourage and promote a philosophy
More informationPrepared Jointly by the American Society of Health-System Pharmacists and the Academy of Managed Care Pharmacy
Required and Elective Educational Outcomes, Educational Goals, Educational Objectives, and Instructional Objectives for Postgraduate Year One (PGY1) Managed Care Pharmacy Residency Programs Prepared Jointly
More informationResponse to Safety Events Just Culture HR Policy 5.24 Page 1 of 10
Response to Safety Events Just Culture HR Policy 5.24 Page 1 of 10 Policy : 5.24 Subject: Supersedes: Effective: October 8, 2008 Revised: July 1, 2002, December 1, 2012 Reviewed: December 1, 2012 Response
More informationThe 10 Building Blocks of Primary Care Building Blocks of Primary Care Assessment (BBPCA)
The 10 Building Blocks of Primary Care Building Blocks of Primary Care Assessment (BBPCA) Background and Description The Building Blocks of Primary Care Assessment is designed to assess the organizational
More informationN C MPASS. Clinical Self-Scheduling. Version 6.8
N C MPASS Clinical Self-Scheduling Version 6.8 Ontario Telemedicine Network (OTN) All rights reserved. Last update: May 24, 2018 This document is the property of OTN. No part of this document may be reproduced
More informationPrivacy and Security Training for Connecting Ontario. PACE Cardiology April, 2017
Privacy and Security Training for Connecting Ontario PACE Cardiology April, 2017 Session Goals By the end of this session you will: Review key elements of privacy protection Know your privacy obligations
More informationUPMC POLICY AND PROCEDURE MANUAL
UPMC POLICY AND PROCEDURE MANUAL POLICY: INDEX TITLE: HS-PT1200 Patient Safety SUBJECT: Reportable Patient Events DATE: December 4, 2015 I. POLICY It is the policy of UPMC to encourage and promote a philosophy
More informationMerced College Registered Nursing 34: Advanced Medical/Surgical Nursing and Pediatric Nursing
Merced College Registered Nursing 34: Advanced Medical/Surgical Nursing and Pediatric Nursing Course Description, Student Learning Outcomes and Competencies, Clinical Evaluation Tool, and Clinical Activities
More informationE.H.R. s and Improving Patient Safety - What Has Been the Real Impact?
E.H.R. s and Improving Patient Safety - What Has Been the Real Impact? Presented by: Mary Erickson, RN, HTS Accounting Manager HTS, a division of Mountain Pacific Quality Health Foundation 1 Understand
More informationAPPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS
APPENDIX 8-2 CHECKLISTS TO ASSIST IN PREVENTING MEDICATION ERRORS Use the following checklists in the appropriate areas of your office, facility or practice to assist in preventing medications errors:
More informationCompliance and Enforcement Standards Pursuant to the Nova Scotia Day Care Act and Regulations
Compliance and Enforcement Standards Pursuant to the Nova Scotia Day Care Act and Regulations Effective Date: September 1, 2017 To ensure you are accessing up-to-date information, please refer to the online
More informationHospital Readmissions Survival Guide
WHITE PAPER Hospital Readmissions Survival Guide The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT into Health Information Technology (HIT) March 2017 In this survival guide,
More informationSecurity Risk Analysis and 365 Days of Meaningful Use. Rodney Gauna & Val Tuerk, Object Health
Security Risk Analysis and 365 Days of Meaningful Use Rodney Gauna & Val Tuerk, Object Health 2 3 Agenda Guidelines for Conducting a Security Risk Analysis Scope of Analysis Risk of a Breach Security Risks
More informationComment Template for Care Coordination Standards
GENERAL COMMENTS Thank you for the opportunity to provide input into these very important standards. We offer the following comments in the spirit of improving clarity, consistency, and ease of reading
More informationED0028 Adverse event, critical incident, serious issue, and near miss procedure
ED0028 Adverse event, critical incident, serious issue, and near miss procedure 1. Full description Adverse event, critical incident, serious issue, 2. Preamble Doctors working in Australia have responsibilities
More informationPage 1 of 5 Version No: 6 Authorised by: General Counsel
Feedback Action Analysis Prioritisation Classificattion Notification Identification INCIDENT MANAGEMENT Patient informed / Family informed if required Event occurs If staff injury form must be printed,
More informationCHAPTER 12 -QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT
CHAPTER 12 -QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT 12.0 QUALITY MANAGEMENT REQUIREMENTS Health Choice Integrated Care works in partnership with providers to continuously monitor and improve the
More informationFundamentals of Self-Limiting Conditions Prescribing for Manitoba Pharmacists. Ronald F. Guse Registrar College of Pharmacists of Manitoba (CPhM)
Fundamentals of Self-Limiting Conditions Prescribing for Manitoba Pharmacists Ronald F. Guse Registrar College of Pharmacists of Manitoba (CPhM) 1 Learning Objectives Upon successful completion of this
More informationSelect the correct response and jot down your rationale for choosing the answer.
UNC2 Practice Test 2 Select the correct response and jot down your rationale for choosing the answer. 1. If data are plotted over time, the resulting chart will be a (A) Run chart (B) Histogram (C) Pareto
More informationPeer Review in Group Practices
Peer Review in Group Practices This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may
More informationAccident Investigation: Root Cause Analysis
Accident Investigation: Root Cause Analysis Patricia J. Boyer, MSM, RN, NHA President/Operations Consultant Boyer & Associates, LLC 16655 W. Bluemound Rd. Ste. 170 Brookfield, WI 53005 Ph.: 262-754-0525
More informationQAPI Quality Assurance Process Improvement
QAPI Quality Assurance Process Improvement Presented by: Sharon M. Litwin, RN, BSHS, MHA, HCS D Senior Managing Partner 5 Star Consultants, LLC 2017 Final Rule in the Federal Register of January 13, 2017
More informationWestern State Hospital
Western State Hospital Organization ID: 1630 9601 Steilacoom Boulevard. S.WLakewood, WA 98498 Accreditation Activity - 60-day Evidence of Standards Compliance Form Due Date: 4/6/2015 Standard HR.01.02.05
More informationTransitional Care Management Services: New Codes, New Requirements
Transitional Care Management Services: New Codes, New Requirements hospital 99496 99495 99496 family practice o n Jan. 1, 2013, the much anticipated transitional care management (TCM) Two new codes will
More informationPI Team: N/A. Medical Staff Officervices Printed copies are for reference only. Please refer to the electronic copy for the latest version.
Document Owner: Karyn Delgado, Teresa Onken Approver(s): Karyn Delgado, Teresa Onken PI Team: N/A Location: Saint Joseph Regional Medical Center-Mishawaka Date Created: 09/01/2001 Date Approved: 10/01/2001
More informationToward the Electronic Patient Record:
June 2007 Toward the Electronic Denise Henderson Director, Consulting Services MedSynergies, Inc. Toward the Electronic The TEPR (Toward the Electronic Patient Record) conference held by the Medical Records
More informationSASKATCHEWAN ASSOCIATIO
SASKATCHEWAN ASSOCIATIO N Standards & Competencies for RN Specialty Practices Effective May 1, 2018 Table of Contents Background Introduction Requirements for RN Specialty Practices RN Procedures and RN
More informationHospital Readmissions
Hospital Readmissions The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT TM Into Health Information Technology (HIT) In this survival guide, we ll give you the tips you need
More informationNURSE PRACTITIONER STANDARDS FOR PRACTICE
NURSE PRACTITIONER STANDARDS FOR PRACTICE February 2012 Acknowledgement The College of Registered Nurses of Prince Edward Island gratefully acknowledges permission granted by the Nurses Association of
More informationMedicine Reconciliation FREQUENTLY ASKED QUESTIONS NATIONAL MEDICATION SAFETY PROGRAMME
Medicine Reconciliation FREQUENTLY ASKED QUESTIONS NATIONAL MEDICATION SAFETY PROGRAMME The Process What is medicine reconciliation? Medicine reconciliation is an evidence-based process, which has been
More informationMedicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver Program FY 17 Attachment P7.9.1
QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAMS FOR SPECIALTY PRE-PAID INPATIENT HEALTH PLANS FY 2017 The State requires that each specialty Prepaid Inpatient Health Plan (PIHP) have a quality
More informationObjectives. Key Elements. ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management 5/20/2014
ICAHN Targeted Focus Areas: Staff Competency and Education Quality Processes and Risk Management Matthew Fricker, RPh, MS, FASHP Program Director, ISMP Rebecca Lamis, PharmD, FISMP Medication Safety Analyst,
More informationComprehensive Community Services (CCS) File Review Checklist Comprehensive
This is a sample form developed by the "CCS Statewide QA/QI Work Group", and is available to CCS sites as a sample for consideration of use, modification, and customization. There is no implicit or explicit
More informationPatient-Centered Connected Care 2015 Recognition Program Overview. All materials 2016, National Committee for Quality Assurance
Patient-Centered Connected Care 2015 Recognition Program Overview All materials 2016, National Committee for Quality Assurance Learning Objectives Introduction to Patient-Centered Connected Care and Eligibility
More informationEfficacy of Tympanostomy Tubes for Children with Recurrent Acute Otitis Media Randomization Phase
CONSENT FOR A CHILD TO BE A SUBJECT IN MEDICAL RESEARCH AND AUTHORIZATION TO PERMIT THE USE AND SHARING OF IDENTIFIABLE MEDICAL INFORMATION FOR RESEARCH PURPOSES TITLE Efficacy of Tympanostomy Tubes for
More informationRoot Cause Analysis LITE (RCA Lite)
Root Cause Analysis LITE (RCA Lite) INTRODUCTION The root cause analysis Lite tool is designed to assist Ottawa Hospital teams to review an adverse event or near miss, identify root causes of the event
More informationUnit 2 Clinical Governance & Risk Management Awareness
Unit 2 Clinical Governance & Risk Management Awareness Incl. investigation of accidents, complaints and claims Unit 2 Clinical Governance & Risk Management Awareness Including investigation of accidents,
More informationDirecting and Controlling
NUR 462 Principles of Nursing Administration Directing and Controlling (Leibler: Chapter 7) Dr. Ibtihal Almakhzoomy March 2007 Dr. Ibtihal Almakhzoomy Directing and Controlling Define the management function
More informationClinical Nurse Leader (CNL ) Certification Exam. Subdomain Weights for the CNL Certification Examination Blueprint (effective February 2012)
Clinical Nurse Leader (CNL ) Certification Exam Subdomain Weights for the CNL Certification Examination Blueprint (effective February 2012) Subdomain Weight (%) Nursing Leadership Horizontal Leadership
More informationThe Monthly Publication of the National Hospice and Palliative Care Organization
The Monthly Publication of the National Hospice and Palliative Care Organization Print-friendly PDF From June 2013 Issue Determining Caseloads Gilchrist Hospice Care on Its Process By Regina Shannon Bodnar,
More informationPayment Reforms to Improve Care for Patients with Serious Illness
Payment Reforms to Improve Care for Patients with Serious Illness Discussion Draft March 2017 Payment Reforms to Improve Care for Patients with Serious Illness Page 2 PAYMENT REFORMS TO IMPROVE CARE FOR
More informationNorth Carolina Board of Nursing
Page 1 of 8 RN Practice Info LPN Practice Info NAII Practice Info Advanced RN RULES P ti Additional Topics PREP P 21-36.0221. LICENSE REQUIRED 21-36.0224. COMPONENTS OF NURSING PRACTICE FOR THE REGISTERED
More informationRisk Management in the ASC
1 Risk Management in the ASC Sandra Jones CASC, LHRM, CHCQM, FHFMA sjones@aboutascs.com IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2014 Accreditation Association for Conflict of Interest Disclosure
More informationQuick Guide to A3 Problem Solving
Quick Guide to A3 Problem Solving What is it? Toyota Motor Corporation is famed for its ability to relentlessly improve operational performance. Central to this ability is the training of engineers, supervisors
More informationEthics for Professionals Counselors
Ethics for Professionals Counselors PREAMBLE NATIONAL BOARD FOR CERTIFIED COUNSELORS (NBCC) CODE OF ETHICS The National Board for Certified Counselors (NBCC) provides national certifications that recognize
More informationMEDICAL STAFF BYLAWS MCLAREN GREATER LANSING HOSPITAL
MEDICAL STAFF BYLAWS MCLAREN GREATER LANSING HOSPITAL Final Document May 16, 2016 Horty, Springer & Mattern, P.C. 245957.7 MEDICAL STAFF BYLAWS TABLE OF CONTENTS PAGE 1. GENERAL...1 1.A. PREAMBLE...1 1.B.
More informationTips for PCMH Application Submission
Tips for PCMH Application Submission Remain calm. The certification process is not as complicated as it looks. You will probably find you are already doing many of the required processes, and these are
More informationPatient Blood Management Certification Program. Review Process Guide. For Organizations
Patient Blood Management Certification Program Review Process Guide For Organizations 2018 What's New in 2018 Updates effective in 2018 are identified by underlined text in the activities noted below.
More informationNZWCS Venous Ulcer Clinical Pathway
NZWCS Venous Ulcer Clinical Pathway A clinical pathway is an optimal sequencing and timing of interventions by clinicians for a particular diagnosis or procedure. The NZWCS venous ulcer pathway predicts
More informationModel Of Care: Care Coordination Interdisciplinary Care Team (ICT)
Cal MediConnect 2017 Model Of Care: Care Coordination Interdisciplinary Care Team (ICT) 2017 CMC Annual Training Learning Objectives Define the L.A. Care Cal MediConnect (CMC) Model of Care Describe the
More informationMEDICAL RECORDS (HEALTH INFORMATION) SERVICES
Facility Name: Facility ID#: Surveyor Name: 10.01.05 Preprinted Orders, Order Sets, & Protocols. Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders
More informationMedicaid RAC Audit Results
Medicaid RAC Audit Results Clinical Audits: The RAC Clinical audit goal was to review supporting documentation for necessity of admission and continued stay in long term care for Medicaid residents. There
More information12.01 Safety Management Plan UWHC Administrative Policies
Page 1 of 7 12.01 Safety Management Plan Category: UWHC Administrative Policy Policy Number: 12.01 Effective Date: October 8, 2013 Version: Revision Section: Environmental Safety (Hospital Administrative)
More informationQuality Impact Assessment Policy
Quality Impact Assessment Policy Date: February 2016 Version: 2.1 Review Due: February 2018 Reader information Reference Directorate Document purpose Q005 Quality The purpose of this policy is to set out
More informationChapter 17 EMS Quality Assurance Program February 2009
Division 05 Emergency Medical February 2009 POLICY This General Order establishes policy and procedures for the continuous evaluation and improvement of emergency medical services (EMS) provided by the
More informationQUALITY IMPROVEMENT PROGRAM
QUALITY IMPROVEMENT PROGRAM QI PROGRAM PURPOSE The Physicians Plus Quality Improvement Program is member-centric. It is designed to deliver safe and effective medical and behavioral healthcare, at the
More informationMeaningful Use Hello Health v7 Guide for Eligible Professionals. Stage 1
Meaningful Use Hello Health v7 Guide for Eligible Professionals Stage 1 Table of Contents Introduction 3 Meaningful Use 3 Terminology 5 Computerized Provider Order Entry (CPOE) for Medication Orders [Core]
More informationCommittee on Interdisciplinary Practice Policy and Procedures
Committee on Interdisciplinary Practice Policy and Procedures I. STATEMENT OF POLICY: At Zuckerberg San Francisco General and its affiliated clinics, affiliated and RN staff provide patient care services
More informationCompliance Program Updated August 2017
Compliance Program Updated August 2017 Table of Contents Section I. Purpose of the Compliance Program... 3 Section II. Elements of an Effective Compliance Program... 4 A. Written Policies and Procedures...
More informationBAY-ARENAC BEHAVIORAL HEALTH AUTHORITY POLICIES AND PROCEDURES MANUAL
Page: 1 of 14 Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) that all adverse events, such as unusual events (including risk), critical incidents (including all deaths) and sentinel
More informationAn RHC Patient Centered Medical Home Experience
An RHC Patient Centered Medical Home Experience NARHC October 19, 2017 Kate Hill, RN The Compliance Team MACRA Recognition TCT Recognized for it s PCMH Program Today s Objectives Understand the difference
More informationETHICAL BEHAVIOR AND CONSUMER RIGHTS (EBR)
Principles: Upholding high standards of ethical conduct and advocating for the rights of patients and their family caregivers. The hospice respects and honors the rights of each patient and family it serves.
More informationCoordinated Care Initiative DRAFT Assessment and Care Coordination Standards November 20, 2012
Coordinated Care Initiative DRAFT Assessment and Care Coordination Standards November 20, 2012 Table of Contents CARE COORDINATION GENERAL REQUIREMENTS...4 RISK STRATIFICATION AND HEALTH ASSESSMENT PROCESS...6
More informationCIO Legislative Brief
CIO Legislative Brief Comparison of Health IT Provisions in the Committee Print of the 21 st Century Cures Act (dated November 25, 2016), H.R. 6 (21 st Century Cures Act) and S. 2511 (Improving Health
More informationCHAPTER 9 PERFORMANCE IMPROVEMENT HOSPITAL
CHAPTER 9 PERFORMANCE IMPROVEMENT HOSPITAL PERFORMANCE IMPROVEMENT Introduction to terminology and requirements Performance Improvement Required (Board of Pharmacy CQI program, The Joint Commission, CMS
More informationMEDICAL RECORDS (HEALTH INFORMATION) SERVICES
Facility Name: Facility ID#: Surveyor Name: 10.01.05 Verbal Order Authentication 10.01.05 Requirements. Preprinted Orders, Order Sets, & Protocols. Hospitals may use pre-printed and electronic standing
More informationThis chapter is aimed at site managers or others considering introducing COPE at a facility.
From COPE Handbook: A Process for Improving Quality in Health Services 2003 EngenderHealth chapter 1 The COPE Process and Tools This chapter is aimed at site managers or others considering introducing
More informationINSERT ORGANIZATION NAME
INSERT ORGANIZATION NAME Quality Management Program Description Insert Year SAMPLE-QMProgramDescriptionTemplate Page 1 of 13 Table of Contents I. Overview... Purpose Values Guiding Principles II. III.
More information